Chapter 4 - Dementia Flashcards
What is dementia?
A progressive clinical syndrome characterised by a range of cognitive and behavioural changes
What are the main types of dementia?
Alzheimer’s Disease
Vascular dementia
Dementia with Lewy bodies
Frontotemporal dementia
What is early onset dementia?
Dementia that occurs before 65 years
What usually causes vascular dementia?
Cardiovascular disease, which causes a reduced blood supply to the brain
What condition is Dementia with Lewy Bodies often associated with?
Parkinson’s Disease
How is dementia usually diagnosed?
Based on symptoms and a clinical assessment tool
What are the symptoms of dementia?
Cognitive symptoms
Memory problems
Disorientation
Difficulty carrying out daily tasks
Behavioural problems Aggression Agitation Depression/anxiety Sleep disorders Psychosis
Which dementia has a stepwise pattern with regards to the severity of symptoms?
Vascular dementia
What additional symptoms may be seen with Dementia with Lewy Bodies that aren’t seen in other types of dementia?
Parkinsonian motor features
E.g. Bradycardia, shuffling gait, rigidity
What medications can cause cognitive decline?
Anticholinergics e.g. TCAs Anticonvulsants e.g. phenytoin, phenobarbital Antipsychotics e.g. haloperidol Analgesics e.g. NSAIDs, opioids Benzodiazepines Corticosteroids
What is an example of an assessment tool for dementia?
MMSE
What are the 5 principles of the mental capacity act 2005
Assume capacity Maximise decision making capacity Freedom to make seemingly unwise decisions Best interests of the patient Least invasive option
What is a power of lasting attorney?
A document where a person can nominate someone else to make certain decisions on their behalf when they are unable to do so themselves
What is advanced decision making?
Allows for people who understand the implications of their decisions to state their treatment wishes in advance
Where should treatments for the cognitive symptoms of dementia be initiated?
When can they be issued in primary care?
Secondary care by a specialist
They can then be continued in primary care under a shared care agreement
What is anticholinergic burden and what are the effects of this?
The cumulative effect of taking one or more medications with a high anticholinergic activity
Effects include increased risk of falls, delerium, cognitive decline and possibly dementia
What are some examples of drugs that significantly increase the anticholinergic burden?
Amitriptyline
Antihistamines e.g. chlorphenamine
Antipsychotics e.g. olanzapine, quetiapine
Urinary antispasmodics e.g. solifenacin, tolteridone, oxybutynin
Hyoscine
What drugs are used for the cognitive symptoms associated with dementia, and for which type of dementia are they licensed in?
Donepezil
Rivastigmine
Galantamine
Memantine
Licensed in Alzheimer’s, but also used in some other types of dementia, e.g. dementia with Lewy Bodies
What are some side effects associated with donepezil, rivastigmine, galantamine and memantine?
Nausea, dizziness, headache, muscle stiffness, tremor, bradycardia, hypotension (may increase the risk of falls)
What is the relationship between acetylcholine and dementia?
Ach is the chemical transmitter for the brain cells that run the memory system
In dementia, the production of Ach in the neurones is reduced
What drugs are used in mild Alzheimer’s Disease?
AchE Inhibitors
What drugs are used in moderate Alzheimer’s Disease?
First line - AchE Inhibitors
If these are not effective, add on memantine
If these are contraindicated use memantine alone
What drugs are used in severe Alzheimer’s Disease?
First line - memantine
What can happen if you discontinue AchE Inhibitors?
Worsening cognitive function
What drugs are used in dementia with Lewy bodies?
First line - donepezil, rivastigmine
If these aren’t tolerated:
Mild to moderate disease - galantamine
Severe disease - memantine
When should AchE Inhibitors be given in vascular dementia?
Only if there is coexisting Alzheimer’s, Parkinson’s of dementia with Lewy bodies
What drugs are usually used in vascular dementia?
Aspirin or clopidogrel
Do we use AchE inhibitors or memantine in frontotemporal dementia?
No
When should antipsychotics be used in dementia?
If the patient is at risk at harming themselves or others, or if they are distressed, agitated, experiencing delusions or hallucinations
What is the MRHA warning associated with the use of antipsychotics in dementia?
Increases risk of stroke and small increased risk of death
Which type of dementia can be worsened by antipsychotics?
Dementia with Lewy Bodies (and Parkinson’s disease)
What antipsychotics are used in dementia?
Haloperidol
Lorazepam
What are the options for depression in dementia?
Preferably non-drug options e.g. CBT
Antidepressants can be used if there’s coexisting mental health problems
What options are there for the sleep disturbances associated with dementia?
Sleep hygiene
What is the mechanism of donepezil?
Reversible AchE Inhibitor
What is the dose of donepezil?
Initially 5mg daily for 1 mont
Then increased if necessary to 10mg daily
At what time should donepezil be given and why?
At night
Because it can cause dizziness
It can be taken in the morning if necessary, e.g. if it causes nightmares
What are the cautions of AchE Inhibitors?
Asthma, COPD
Seizures
Risk of peptic ulcers
What is a potentially life threatening side effect of donepezil?
Neuroleptic Malignant Syndrome (NMS)
Symptoms include muscle rigidity, hyperthermia, alternating consciousness
How are rivastigmine patches used?
Apply to clean, dry, non-hairy skin
Leave on for 24 hours
Remove the patch
Apply the next one in a different location
When using rivastigmine patches, should you:
a) apply the new patch before removing the old one
b) remove the old patch before applying the new one?
b) remove the old patch before applying the new one
When using rivastigmine patches, how long should you avoid using the same patch of skin for?
14 days
When should rivastigmine be stopped, and how should it be restarted?
If GI effects occur
If stopped for more than 3 days, the dose will need to be re-titrated
What is the mechanism of rivastigmine and galantamine?
AchE Inhibit
Some nicotinic receptor agonist properties
When should galantamine be discontinued?
When a rash occurs
Could be:
Steven Johnson’s Syndrome
Erythema multiforme
Acute generalised exanthematous pustulosis
What is the dose of memantine?
5mg OD
Increased of steps of 5mg every week
Usual maintenance 20mg
What are the cautions of memantine?
Epilepsy, history of convulsions
